Sickle cell disease (SCD), which results from an inherited mutation in the hemoglobin gene that causes red blood cells to "sickle" under conditions of low oxygen, occurs with a frequency of 1/500 African-Americans, and is also common in Hispanic-Americans, who comprise up to 5% of SCD patients in California. The median survival based on 1991 national data was 42 years for males and 48 years for females. More recent data indicate that the median survival for Southern California patients with SCD is only 36 years, suggesting that serious problems exist regarding access to optimal medical care in this community. By twenty years of age, about 15% of children with SCD suffer major strokes and by 40 years of age, almost half of the patients have had central nervous system damage leading to significant cognitive dysfunction. These patients suffer recurrent damage to lungs and kidneys as well as severe chronic pain that impacts on quality of life. While current medical therapies for SCD can make an important difference in short-term effects, the progressive deterioration in organ function results in compromised quality of life and early deaths in ethnic populations who are generally adversely affected by health care disparity. Transplantation of bone marrow from a healthy donor as a source of new adult blood-forming ("hematopoietic") stem cells can benefit patients with SCD, by providing a source for life-long production of normal red blood cells. However, bone marrow transplant is limited by the availability of well-matched donors and the problems that arise from immune reactions between the cells of the donor and the patient. Thus, despite major improvements in clinical care of SCD patients, SCD continues to be a major cause of illness and early death.
The stem cell therapy approach to be developed by this Disease Team will be used to treat patients with SCD by transplanting them with their own bone marrow adult hematopoietic stem cells that are genetically corrected by adding a hemoglobin gene that blocks sickling of the red blood cells. This approach has the potential to permanently cure this debilitating and common illness with significantly less toxicity than with a bone marrow transplant from another person. A clinical trial using stem cell gene therapy for patients with SCD will be developed to be performed by this Team. This multi-disciplinary Disease Team combines world-leading experts in stem cell gene therapy, clinical bone marrow transplantation and the care of patients with sickle cell disease. Successful use of stem cell gene therapy for sickle cell disease has the potential to provide a more effective and safe treatment for this disease to a larger proportion of affected patients.

Statement of Benefit to California:

Development of methods for regenerative medicine using genetically-corrected human stem cells will result in novel, effective therapies that improve the health for millions of Californians and tens of millions of people world-wide. Sickle cell disease is an inherited disease of the red blood cells that results from a specific gene mutation. Sickle cell disease disproportionately afflicts poor minority patients in the State of California, causing severe morbidity, early mortality and high medical costs. We will develop a clinical trial to evaluate a novel treatment for patients with sickle cell disease, using their own adult blood-forming stem cells, after correcting the hemoglobin gene defect. Successful treatment of sickle cell disease using adult blood forming “hematopoietic” stem cells corrected with gene therapy may provide a clinically beneficial way to treat sickle cell disease with greater safety and wider availability than current options. The clinical trial to be developed will treat sickle cell disease patients from across the state of California through the network of institutions incorporated into this Disease Team. All scientific findings and biomedical materials produced from our studies will be publicly available to non-profit and academic organizations in California, and any intellectual property developed by this Project will be developed under the guidelines of CIRM to benefit the State of California.

Progress Report:

The clinical complications of sickle cell disease are due to the inherited abnormality of the oxygen-carrying hemoglobin protein in red blood cells (RBC). The RBC are made from stem cells in the bone marrow and transplantation of stem cells from the bone marrow of a healthy donor to someone with sickle cell disease (SCD) can lead to significant improvements in their health. However, most people do not have a matched sibling donor, and transplants from unrelated donors have higher risks for complications, mainly due to immune reactions between the donor and the recipient.
The goal of this project is to bring to the clinic a trial of treating patients with SCD by transplanting them with their own bone marrow stem cells that have been modified in the lab by adding the gene for a version of human beta-globin that will act to inhibit sickling of the patient’s RBC (“anti-sickling” gene). This approach may provide a way to improve the health of people with SCD, with advantages over clinical treatments using transplantation of bone marrow stem cells from another person.
The major Year 1 Milestone was to demonstrate the feasibility of this approach, i.e. that the clinical cell product, the subject’s bone marrow stem cells modified with the anti-sickling gene, can be produced suitably for clinical transplantation and that enough of the anti-sickling hemoglobin is made to reverse sickling of RBC made from the gene-modified stem cells.
Studies done by the Laboratory component of our Disease Team showed that the gene transfer lentiviral vector we developed to insert the anti-sickling gene into bone marrow stem cells met pre-set technical criteria for: the amount of vector that can be made, its efficiency to insert the anti-sickling gene into human bone marrow stem cells, the levels of anti-sickling beta-globin protein made by the vector in RBC made from bone marrow stem cells, and the absence of adverse effects on the stem cells or their ability to make new RBC. These successful results allow advancement to the major lab focus for Years 2-3, pre-clinical efficacy and safety studies to support an IND application.
The Clinical/Regulatory component of our Disease team established the proposed network of California clinical hematology sites to obtain bone marrow samples from volunteer donors with SCD for laboratory research studies on cell product development (UCLA, CHLA and CHRCO). We put into place the necessary IRB-approved protocols to collect bone marrow samples at these sites to use for the laboratory research at UCLA and USC. This network obtained its first BM sample from a SCD donor on 3/18/2010 and a total of 15 over the year. These patient-derived samples have been truly essential to the advancement of the laboratory work because bone marrow from SCD patients is needed for studies to measure expression of the anti-sickling gene and improvement in RBC sickling.
The Clinical Regulatory component has also produced a complete first draft of the clinical trial protocol, which defines which specific people with SCD would be eligible for participation in this study, and the exact approach of the clinical study, including how the patients will be evaluated before the procedure, the details of the bone marrow harvest, stem cell processing and transplant processes, and how the effects of the procedure will be assessed. This protocol was conceived with input from the Team of physicians and scientists with expertise in clinical and experimental hematology, bone marrow transplantation, transfusion medicine, gene therapy and cell processing laboratory methods, regulatory affairs, and biostatistics.
These efforts provided sufficient laboratory data and definition of the clinical approach that we could have a pre-pre-IND exchange with the FDA (on 09/30/10). This interaction provided us the opportunity to receive initial guidance for three key areas that would comprise the IND application: the draft clinical protocol, the methods to make and characterize the gene-modified stem cell product for transplant, and the planned pre-clinical safety studies. The meeting was encouraging and informative.
In Year 2, our laboratory work will focus on determining the functional effects of inserting the anti-sickling gene into bone marrow stem cells from SCD donors on sickling of the RBC. We will begin to define the laboratory test methods that would be used to measure the results in the clinical trial (% of stem and blood cells with the gene, the amounts of anti-sickling beta-globin made, and the effects on RBC sickling). We will continue to design the studies to formally test vector safety (Toxicology study). The major goal is to advance to a pre-IND meeting with the FDA which should provide further guidance to finalize the design of the pre-clinical toxicology study and the clinical trial design. We will then be ready to implement the toxicology study and begin regulatory reviews of the protocol by local and federal authorities.

The clinical complications of sickle cell disease are due to the inherited abnormality of the oxygen-carrying hemoglobin protein in red blood cells (RBC). The RBC are made from stem cells in the bone marrow and transplantation of stem cells from the bone marrow of a healthy donor to someone with sickle cell disease (SCD) can lead to significant improvements in their health. However, most people do not have a matched sibling donor, and transplants from unrelated donors have higher risks for complications, mainly due to immune reactions between the donor and the recipient.
The goal of this project is to bring to the clinical trial of treating patients with SCD by transplanting them with their own bone marrow stem cells that have been modified in the laboratory by adding the gene for a version of human beta-globin that will act to inhibit sickling of the patient’s RBC (“anti-sickling” gene). This approach may provide a way to improve the health of people with SCD, with advantages over clinical treatments using transplantation of bone marrow stem cells from another person.
In the first 2 years of this project we were able to demonstrate the feasibility of this approach, i.e. that the clinical cell product, the subject’s bone marrow stem cells modified with the anti-sickling gene, can be produced suitably for clinical transplantation and that enough of the anti-sickling hemoglobin is made to reverse sickling of RBC made from the gene-modified stem cells.
Studies done by the Laboratory component of our Disease Team showed that the gene transfer lentiviral vector we developed to insert the anti-sickling gene into bone marrow stem cells met pre-set technical criteria for: the amount of vector that can be made, its efficiency to insert the anti-sickling gene into human bone marrow stem cells, the levels of anti-sickling beta-globin protein made by the vector in RBC, and the absence of adverse effects on the stem cells or their ability to make new RBC. These successful results allow advancement to the major lab focus for Year 3, safety studies to support an IND application.
The Clinical/Regulatory component of our Disease team established the proposed network of California clinical hematology sites to obtain bone marrow samples from volunteer donors with SCD for laboratory research studies on cell product development (UCLA, CHLA and CHRCO). We put into place the necessary IRB-approved protocols to collect bone marrow samples at these sites to use for the laboratory research at UCLA and USC. This network obtained its first BM sample from a SCD donor on 3/18/2010 and a total of 29 over 2 years. These patient-derived samples have been truly essential to the advancement of the laboratory work because bone marrow from SCD patients is needed for studies to measure expression of the anti-sickling gene and improvement in RBC sickling.
The Clinical Regulatory component has also produced a complete first draft of the clinical trial protocol, which defines which specific people with SCD would be eligible for participation in this study, and the exact approach of the clinical study, including how the patients will be evaluated before the procedure, the details of the bone marrow harvest, stem cell processing and transplant processes, and how the effects of the procedure will be assessed. This protocol was conceived with input from the Team of physicians and scientists with expertise in clinical and experimental hematology, bone marrow transplantation, transfusion medicine, gene therapy and cell processing laboratory methods, regulatory affairs, and biostatistics.
These efforts provided sufficient laboratory data and definition of the clinical approach that we could have a pre-IND meeting with the FDA (on 08/22/11). This interaction provided us the opportunity to receive guidance for three key areas that would comprise the IND application: the draft clinical protocol, the methods to make and characterize the gene-modified stem cell product for transplant, and the planned pre-clinical safety studies. The meeting was encouraging and informative.
In Year 3, our laboratory work will focus on performing pre-clinical safety studies (Toxicology study), qualifying end point assays and finalizing stem cell processing.

The clinical complications of sickle cell disease are due to the inherited abnormality of the oxygen-carrying hemoglobin protein in red blood cells (RBC). The RBC are made from stem cells in the bone marrow and transplantation of stem cells from the bone marrow of a healthy donor to someone with sickle cell disease (SCD) can lead to significant improvements in their health. However, most people do not have a matched sibling donor, and transplants from unrelated donors have higher risks for complications, mainly due to immune reactions between the donor and the recipient.
The goal of this project is to develop a clinical trial to treat patients with SCD by transplanting them with their own bone marrow stem cells that have been modified in the laboratory by adding the gene for a version of human beta-globin that will act to inhibit sickling of the patient’s RBC (“anti-sickling” gene). This approach may provide a way to improve the health of people with SCD, with advantages over clinical treatments using transplantation of bone marrow stem cells from another person.
In the first 2 years of this project we demonstrated the feasibility of this approach, i.e. that the clinical cell product, the subject’s bone marrow stem cells modified with the anti-sickling gene, can be produced suitably for clinical transplantation and that enough of the anti-sickling hemoglobin is made to reverse sickling of RBC made from the gene-modified stem cells. The Clinical/Regulatory component of our Disease Team established the proposed network of California clinical hematology sites to obtain bone marrow samples from volunteer donors with SCD for laboratory research studies on cell product development (UCLA, CHLA and CHRCO). We put into place the necessary IRB-approved protocols to collect bone marrow samples at these sites to use for the laboratory research at UCLA and USC. This network obtained its first BM sample from a SCD donor on 3/18/2010 and a total of 45 over 3 years. These patient-derived samples have been truly essential to the advancement of the laboratory work because bone marrow from SCD patients is needed for studies to measure expression of the anti-sickling gene and improvement in RBC sickling. The Clinical Regulatory component has also produced the clinical trial protocol, which defines which specific people with SCD would be eligible for participation in this study, and the exact approach of the clinical study, including how the patients will be evaluated before the procedure, the details of the bone marrow harvest, stem cell processing and transplant processes, and how the effects of the procedure will be assessed. This protocol was conceived with input from the Team of physicians and scientists with expertise in clinical and experimental hematology, bone marrow transplantation, transfusion medicine, gene therapy and cell processing laboratory methods, regulatory affairs, and biostatistics.
During the third year the Clinical Gene Therapy Laboratory component of the Team has demonstrated the feasibility of the stem cell processing procedure. Mimicking the future clinical scenario, the Lab was able to isolate stem cells from a largescale bone marrow harvest, insert the anti-sickling gene in adequate amount and recover the needed amount of stem cells that would be transplanted into the patient. The Clinical/Regulatory component of our Disease Team is focusing on validating all the assays that will be used during the clinical trial i.e. to characterize the final cell product and also the end-point assays to analyze the efficacy of this approach in patients. Another major focus during the third year has been safety and toxicology studies in a murine model of bone marrow transplant; the studies are still ongoing and will be completed in the next year. These successful results allow advancement to support an IND application in year 4.

CIRM DR1-01452 - Stem Cell Gene Therapy for Sickle Cell Disease
Scientific Progress in Year 4
The clinical complications of sickle cell disease are due to the inherited abnormality of the oxygen-carrying hemoglobin protein in red blood cells (RBC). The RBC are made from stem cells in the bone marrow and transplantation of stem cells from the bone marrow of a healthy donor to someone with sickle cell disease (SCD) can lead to significant improvements in their health. However, most people do not have a matched sibling donor, and transplants from unrelated donors have higher risks for complications, mainly due to immune reactions between the donor and the recipient.
The goal of this project is to develop a clinical trial to treat patients with SCD by transplanting them with their own bone marrow stem cells that have been modified in the laboratory by adding the gene for a version of human beta-globin that will act to inhibit sickling of the patient’s RBC (“anti-sickling” gene). This approach may provide a way to improve the health of people with SCD, with advantages over clinical treatments using transplantation of bone marrow stem cells from another person.
In the first 2 years of this project, we demonstrated the feasibility of this approach, i.e. that the clinical cell product, the subject’s bone marrow stem cells modified with the anti-sickling gene, can be produced suitably for clinical transplantation and that enough of the anti-sickling hemoglobin is made to reverse sickling of RBC made from the gene-modified stem cells. The Clinical/Regulatory component of our Disease Team established the proposed network of California clinical hematology sites to obtain bone marrow samples from volunteer donors with SCD for laboratory research studies on cell product development (UCLA, CHLA and CHRCO). We put into place the necessary IRB-approved protocols to collect bone marrow samples at these sites to use for the laboratory research at UCLA and USC. This network obtained its first BM sample from a SCD donor on 3/18/2010 and a total of 56 over 4 years. These patient-derived samples have been truly essential to the advancement of the laboratory work because bone marrow from SCD patients is needed for studies to measure expression of the anti-sickling gene and improvement in RBC sickling. The Clinical Regulatory component has also produced the clinical trial protocol, which defines which specific people with SCD would be eligible for participation in this study, and the exact approach of the clinical study, including how the patients will be evaluated before the procedure, the details of the bone marrow harvest, stem cell processing and transplant processes, and how the effects of the procedure will be assessed. This protocol was conceived with input from the Team of physicians and scientists with expertise in clinical and experimental hematology, bone marrow transplantation, transfusion medicine, gene therapy and cell processing laboratory methods, regulatory affairs, and biostatistics. It has now been approved by the UCLA Institutional Review Board and the Institutional Scientific Protocol review Committee, as well as the NIH Recombinant DNA Advisory Committee.
During the last 2 years the Clinical Gene Therapy Laboratory component of the Team has demonstrated the feasibility of the stem cell processing procedure. Mimicking the future clinical scenario, the Lab was able to isolate stem cells from a large scale bone marrow harvest, insert the anti-sickling gene in adequate amount and recover the needed amount of stem cells that would be transplanted into the patient. The Clinical/Regulatory component of our Disease Team validated all the assays that will be used during the clinical trial i.e. to characterize the final cell product and also the end-point assays to analyze the efficacy of this approach in patients. Another major focus during the third and fourth year has been safety and toxicology studies in a murine model of bone marrow transplant; these successful results allow advancement to support an IND application in the second quarter of 2014, with a goal of opening the trial in the third quarter of the year.

The clinical complications of sickle cell disease are due to the inherited abnormality of the oxygen-carrying hemoglobin protein in red blood cells (RBC). The RBC are made from stem cells in the bone marrow and transplantation of stem cells from the bone marrow of a healthy donor to someone with sickle cell disease (SCD) can lead to significant improvements in their health. However, most people do not have a matched sibling donor, and transplants from unrelated donors have higher risks for complications, mainly due to immune reactions between the donor and the recipient.
The goal of this project is to develop a clinical trial to treat patients with SCD by transplanting them with their own bone marrow stem cells that have been modified in the laboratory by adding the gene for a version of human beta-globin that will act to inhibit sickling of the patient’s RBC (“anti-sickling” gene). This approach may provide a way to improve the health of people with SCD, with advantages over clinical treatments using transplantation of bone marrow stem cells from another person.
In the first 2 years of this project, we demonstrated the feasibility of this approach, i.e. that the clinical cell product, the subject’s bone marrow stem cells modified with the anti-sickling gene, can be produced suitably for clinical transplantation and that enough of the anti-sickling hemoglobin is made to reverse sickling of RBC made from the gene-modified stem cells. The Clinical/Regulatory component of our Disease Team established the proposed network of California clinical hematology sites to obtain bone marrow samples from volunteer donors with SCD for laboratory research studies on cell product development (UCLA, CHLA and CHRCO). We put into place the necessary IRB-approved protocols to collect bone marrow samples at these sites to use for the laboratory research at UCLA and USC. This network obtained its first BM sample from a SCD donor on 3/18/2010 and a total of 58 over 4+ years. These patient-derived samples have been truly essential to the advancement of the laboratory work because bone marrow from SCD patients is needed for studies to measure expression of the anti-sickling gene and improvement in RBC sickling. The Clinical Regulatory component has also produced the clinical trial protocol, which defines which specific people with SCD would be eligible for participation in this study, and the exact approach of the clinical study, including how the patients will be evaluated before the procedure, the details of the bone marrow harvest, stem cell processing and transplant processes, and how the effects of the procedure will be assessed. This protocol was conceived with input from the Team of physicians and scientists with expertise in clinical and experimental hematology, bone marrow transplantation, transfusion medicine, gene therapy and cell processing laboratory methods, regulatory affairs, and biostatistics. It has now been approved by the UCLA Institutional Review Board and the Institutional Scientific Protocol review Committee, as well as the NIH Recombinant DNA Advisory Committee.
During the last 2 years the Clinical Gene Therapy Laboratory component of the Team has demonstrated the feasibility of the stem cell processing procedure. Mimicking the future clinical scenario, the Lab was able to isolate stem cells from a large scale bone marrow harvest, insert the anti-sickling gene in adequate amount and recover the needed amount of stem cells that would be transplanted into the patient. The Clinical/Regulatory component of our Disease Team validated all the assays that will be used during the clinical trial i.e. to characterize the final cell product and also the end-point assays to analyze the efficacy of this approach in patients. Another major focus during the third and fourth year has been to demonstrate the safety of this approach in a murine model of bone marrow transplant; these successful results allowed advancement to support an IND application and opening a clinical trial for gene therapy of SCD in the second quarter of 2014.